- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $14,125.38
| Facility | | $1,380.38 | $4,897.79 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $15,488.17 / $15,488.17
| Professional | | $1,023.29 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,454.40 / $20,417.38
| Facility | | $6,456.54 | $14,454.40 | $20,417.38 |